Mr. Gordon - Stroke

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Contents

Background Information

Mr. Jeff Gordon is a 66-year-old retired accountant who lives in London. He is married to Mona, age 62, who is a homemaker. Mona has had emphysema for years and has relied on her husband to help with housework and preparation of some meals. They have a son, Joshua, age 30, who has followed in his father's footsteps as an accountant and a daughter, Andrea, age 26, who is a nurse.

Mr. Gordon was sitting watching TV one evening last month when he suddenly developed a generalized headache and nausea. His wife noticed that his speech had become slurred and his left arm and leg were clumsy. Within thirty minutes, he was drowsy and no longer able to walk. He had smoked one package of cigarettes daily for 40 years and was treated with insulin for diabetes mellitus for the previous five years.

Mr. Gordon was taken by ambulance to emergency at London Health Sciences Centre and admitted to hospital. His vital signs were stable with a blood pressure of 160/92 and a regular heart rate of 84 per minute. He was drowsy but rousable so that he could answer simple questions. He denied having anything wrong with his left side. His speech was slurred and he did not appear to be able to see to the left. He tended to keep his eyes deviated to the right. There was a droop of the left side of his lower face and saliva drooled from the left corner of his mouth. Although he made some voluntary movements of his left arm and leg, he could not maintain his left arm or leg in the air against gravity. His left side showed decreased tone and the deep tendon reflexes were decreased relative to the right. He did not respond to pinprick or pinch of his left side and, with his eyes closed, could not detect the direction of passive movement of his left hand or foot. He was incontinent of urine.

Mr. Gordon underwent a CT scan of the head which showed a large right cerebral hemisphere stroke. He was treated with aspirin as an anti-platelet agent and started on physiotherapy. His diabetes remained well-controlled with a slight adjustment in his insulin. He regained bladder control and his bowels moved regularly with the aid of a bowel stimulant. He became alert and recognized that his left side was weak, but still could not see to the left. He developed anti-gravity power in his left leg, but only had a flicker of movement in his left arm. The tone in his left side became increased with increased deep tendon reflexes. He still had marked sensory loss in his left arm and leg.

After spending two weeks at London Health Sciences Centre, he was transferred to Parkwood Hospital for further rehabilitation. His level of function appeared to stabilize. He has become depressed as a result of his disability and rarely initiates any conversation. He has to be encouraged to eat anything and he sleeps poorly. Mr. Gordon has previously been well apart from treatment with insulin for diabetes mellitus over the past five years. He has smoked one pack of cigarettes daily for the past forty years. His father died following a stroke at the age of 72. He was also diabetic. His mother died of "old age" at 85. Mr. Gordon has a younger sister who is well at age 60.

Mr. and Mrs. Gordon have been devastated by this stroke. They recognize that he likely will remain confined to a wheelchair and will not be able to transfer in and out of the wheelchair without the aid of 1 or 2 people. The Gordons cannot afford 24-hour home care and it seems likely that he will need to be maintained in a nursing home. This has major implications for Mrs. Gordon who will have difficulty maintaining the home on her own. All of this has been extremely distressing for their son and daughter, Joshua and Andrea.

Learning Issues

There are a lot of issues! Each group should choose some from each section below.

Disease

Causes of strokes and explanation of signs, symptoms, etc.

  • Hospital (inpatient) strokes
    • risk factors from �In-hospital Science� Lancet (2), Dec 2003
  • Signs and symptoms
    • facial paralysis, messed up brain stuffs, maybe neglect

Incidence, prevalence, and demographic distribution of strokes

  • 730 000 per year
  • mortality: 27%
  • leading cause of disability

Investigation and diagnosis of stroke

  • 24 hour rule-in period?
  • 911 times?

Types of stroke, clinical course and treatments (both short-term and long-term)

  • medication (pharmacological)
  • acute thrombolytic treatments
  • Prognosis? 27% mortality

Illness

How does personality and mood change in a patient who has suffered a stroke?

  • Depends on where they were struck (could be physiological)
  • could be biological or psychological
  • biological � left sided strokes more frequently cause this
  • Even if all no emotional centres were struck, other factors could make person feel shitty

How do patient�s attitudes affect their disease progression and outcomes?

  • Quality of life � physical function, mental, etc.
  • Many ratings decrease after departure from hospital
  • could indicate that they�re pissed off more once they�re in the real world
  • Could increase resolve
  • if they�re constantly angry, it affects caregivers and caregiver care � feelings of frustration and such.
  • Starting physiotherapy right away makes it more likely they move on

Person

What happens when the cared-for becomes the caregiver and vice versa?

  • 55% of people who care for spouse end up with emotional distress
  • compounded if the stroke patient has dementia or other mental problems

How is the role of family changing in providing health care to patients with long-term illnesses

Is the health care system capable of providing adequate end-stage care?

What happens to critically ill patients during "holiday time"? Do holidays affect access to treatment and if so, do these delays affect outcome?

Context

What is the difference between a Nursing Home and a Home for the Aged? How are these funded?

What legislation is in place to protect residents of Nursing Homes and Homes for the Aged? Can this legislation be used to address the Gordons� wish that they remain together?

  • Hints: See here and here!)
  • Nursing Home Act, 2.14. Every resident has the right to meet privately with his or her spouse or same-sex partner in a room that assures privacy and where both spouses or same-sex partners are residents in the same nursing home, they have a right to share a room according to their wishes, if an appropriate room is available.

What services in the community are available to help the Gordons and other stroke survivors?

What is involved in stroke rehabilitation? Who sets rehab goals and monitors patient progress in attaining these goals?

  • Exercise, adaptive techniques, assistive devices
  • speech therapy, etc

What are the costs associated with treatments?

  • Lots o� money

Resources

  • Code Gray - An organized approach
  • In Hospital strokes
  • Outcome measures in Stroke
  • Pharmacological treatment of stroke
  • Stroke historical perspectives